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Clinical Edits

The Texas Managed Medicaid STAR/CHIP formulary, including the Preferred Drug List and any clinical edits, is defined by the Texas Vendor Drug Program.

Texas Vendor Drug Program Clinical Edit Website: https://www.txvendordrug.com/formulary/prior-authorization/mco-clinical-pa

Please click on the link(s) below to view the Texas Medicaid STAR and CHIP implemented clinical edits.

Click here for Prior Authorization information.

Type Name File Size
PDF File Accolate
Eff. Date: 1/18/2018
 ACCOLATE, ZAFIRLUKAST 292 KB
PDF File ADD_ADHD
Eff. Date: 07/26/2018
 ADDERALL, AMPHETAMINE/DEXTROAMPHET SALTS, DESOXYN, DEXMETHYLPHENIDATE, EVEKEO, FOCALIN, METHAMPHETAMINE, METHYLIN, METHYLPHENIDATE, PROCENTRA, RITALIN, ZENZEDI, ADZENYS, AMPHETAMINE/DEXTROAMPHET SALTS ER, APTENSIO XR, CONCERTA ER, COTEMPLA, DAYTRANA, DEXEDRINE, DEXMETHYLPHENIDATE, DYANAVEL, FOCALIN XR, METADATE, METHYLPHENIDATE ER, METHYLPHENIDATE CD, MYDAYIS, QUILLICHEW, QUILLIVANT, RITALIN, VYVANSE, GUANFACINE, INTUNIV, STRATTERA, CLONIDINE 541 KB
PDF File Agents for Gaucher’s Disease - HHSC
Eff. Date: 07/31/2015
 CEREZYME, ELELYSO, VPRIV, ZAVESCA 1 MB
PDF File Alinia - HHSC
Eff. Date: 05/27/2016
 ALINIA 433 KB
PDF File Aliskiren - HHSC
Eff. Date: 05/31/2016
 TEKAMLO, TEKTURNA, AMTURNIDE, TEKTURNA HCT 2 MB
PDF File Allergen Extracts - HHSC
Eff. Date: 11/09/2018
 ORALAIR 471 KB
PDF File Antiemetics - HHSC
Eff. Date: 05/27/2016
 AKYNZEO, ANZEMET, APREPITANT, EMEND, GRANISETRON HCL, SANCUSO 372 KB
PDF File Antipsychotics
Eff. Date: 09/01/2018
 ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA ER, AMITRIPTYLINE/PERPHENAZINE, ARIPIPRAZOLE, ARISTADA ER, CHLORPROMAZINE, CLOZAPINE, CLOZARIL, FANAPT, FANAPT TITRATION PACK, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA, INVEGA ER, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, LOXITANE, MOLINDONE, OLANZAPINE, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE ER, PERPHENAZINE, PIMOZIDE, QUETIAPINE, QUETIAPINE ER, REXULTI, RISPERDAL, RISPERDAL CONSTA, RISPERDAL M-TAB ODT, RISPERIDONE, RISPERIDONE ODT, SAPHRIS, SEROQUEL, SEROQUEL XR, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS 429 KB
PDF File Anxiolytics and Sedatives Hypnotics (ASHs) - HHSC
Eff. Date: 10/12/2018
 ALPRAZOLAM, XANAX, CHLORDIAZEPOXIDE, MEPROBAMATE, OXAZEPAM, DIAZEPAM, CLONAZEPAM, KLONOPIN, CLORAZEPATE, TRANXENE T, LORAZEPAM, TEMAZEPAM, TRIAZOLAM, ZOLPIDEM, ESTAZOLAM, RESTORIL, TEMAZEPAM, ESZOPICLONE, LUNESTA, SONATA, ZALEPLON, INTERMEZZO, ZOLPIDEM, AMBIEN, EDLUAR, BELSOMRA, BUTISOL SODIUM, FLURAZEPAM, ROZEREM 847 KB
PDF File Buprenorphine Agents – HHSC
Eff. Date: 03/26/2018
 BUNAVAIL, BUPRENORPHINE, BUPRENORPHINE-NALOXON, SUBOXONE, ZUBSOLV 1 MB
PDF File Carisoprodol - HHSC
Eff. Date: 07/27/2018
 CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND, CARISOPRODOL CPD-CODEINE, CARISOPRODOL, SOMA 359 KB
PDF File Celebrex
Eff. Date: 06/15/2017
 CELEBREX 367 KB
PDF File CGRP Antagonists - HHSC
Eff. Date 10/31/2018
 AIMOVIG 392 KB
PDF File Contraceptives - CHIP ONLY
Eff. Date: 10/22/2012
 22 KB
PDF File Contraceptives - Dell Children’s Health Plan Only
Eff. Date: 12/09/2016
 18 KB
PDF File Cough/Cold Medications - HHSC
Eff. Date: 02/12/2018
 ALA-HIST, ALLFEN DM TAB, AP-HIST DM LIQ, APRODINE TAB, BENZONATATE, BROMFED DM CGH SYR, BROMPHENIR-PSEUDO-DM SYR, BROTAPP, CHEST CONG RELIEF, CHLD DELSYM, CHLD COLD & CGH DM ELIXI, CHLD MUCINEX, CHLO TUSS LIQ, CGH DM, CGH SYR, DALLERGY, DECONEX DMX TAB, DECONEX IR TAB, DELSYM, DEXTROMETHORPHAN ER, DIMAPHEN, ED A-HIST, ED BRON GP LIQ, ED CHLORPED D PEDIATRIC DROPS, ENDACOF-DM LIQ, EX ACTION CGH SYR, GUAIFEN, GUAIFEN ER, GUAIFEN/PSE, HISTEX, IOPHEN, KIDKARE CGH & COLD LIQ, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LOHIST, LORTUSS, MAXIPHEN, M-END DMX LIQ, M-HIST DM LIQ, MUCINEX, MUCUS RELIEF, NASAL DECON SPRAY, NASOPEN PE LIQ, NINJACOF LIQ, NOHIST, NOSE DROPS, ORGAN-I, PEDIATRIC CGH-COLD LIQ, PHENYLEPHRINE-PYRILAMINE, POLY HIST, POLY-VENT, PROMETHAZINE, Q-TUSS, RESCON, RESPAIRE-30, ROBAFEN, RU-HIST D, RYMED, SILTUSS, SM NASAL SPRAY, SM TUSS DM, STAHIST AD, SUDOGEST SINUS & ALLERGY TAB, TUSS, VANACOF, VANATAB 424 KB
PDF File Cystic Fibrosis Agents - HHSC
Eff. Date: 11/27/2018
 KALYDECO, ORKAMBI, SYMDEKO 667 KB
PDF File Cytokine and CAM Antagonists
Eff. Date: 10/10/2018
 ACTEMRA, CIMZIA, COSENTYX, ENBREL, HUMIRA, ILARIS, KEVZARA, KINERET, ORENCIA, OTEZLA, SILIQ, SIMPONI, STELARA, TALTZ, TREMFYA, XELJANZ 2 MB
PDF File Desmopressin
Eff. Date: 05/01/2018
 DDAVP, DESMOPRESSIN ACETATE 378 KB
PDF File Dextromethorphan Overutilization - HHSC
Eff. Date: 07/17/2018
 ALA-HIST DM LIQ, AP-HIST DM LIQ, ALLFEN DM TAB, BROMFED DM CGH, BROMPHENIR-PSEUDO-DM SYR, BROTAPP DM LIQ, CHILD DELSYM, CHILD C&C DM ELIX, CHILD MUCINEX, DECONEX DMX TAB, DELSYM 30MG/5ML SUSP, DELSYM CGH+CHEST CNGST DM LQ, DEXTROMETHORPHAN ER 30MG/5ML, DIMAPHEN DM ELIX, ED-A-HIST DM LIQ, ED-A-HIST DM TAB, ENDACOF-DM LIQ, EXT ACTION CGH SYR, GUIAFEN-DM ER 1,200-60MG TAB, HISTEX-DM SYR, IOPHEN DM-NR LIQ, KIDKARE C&C LIQ, LOHIST-DM SYR, LORTUSS DM LIQ, M-END DMX LIQ, M-HIST DM, MAXIPHEN DM TAB, MUCINEX CGH MINI-MELT PACK, MUCINEX DM ER 600-30MG TAB, MUCINEX DM ER 1,200-60MG TAB, MUCINEX FAST-MAX CONG-CGH, MUCINEX FAST-MAX DM MAX LIQ, NOHIST-DM LIQ, PED C&C LIQ, POLY-HIST DM LIQ, POLY-VENT DM TAB, PROMETH-DM SYR, Q-TUSS DM SYR, RESCON-DM LIQ, ROBAFEN CF LIQ, ROBAFEN-DM, ROBAFEN CGH 15MG LIQGEL, ROBAFEN DM CGH-CHEST CONG SYR, RYNEX DM LIQ, SILTUSS DM CGH SYR, SILTUSS DM DAS LIQ, SM TUSS DM, TUSS DM, VANACOF DM LIQ, VANATAB DM CAP, VIRDEC DM DRP 248 KB
PDF File Diclofenac - HHSC
Eff. Date: 08/03/2017
 DICLOFENAC GEL 3%, DICLOFENAC SOL 1.5%, PENNSAID SOL 2% 401 KB
PDF File DPP4 Inhibitors - HHSC
Eff. Date: 04/03/2018
 ACTOPLUS MET XR , ALOG/PIOGLIP , ALOGLIPTIN , ALOGLIPTIN/METFORM , DUETACT , GLIP/METFORM , GLUCOVANCE , GLYB/METFORM , GLYXAMBI , INVOKAMET , JANUMET , JANUMET XR , JANUVIA , JENTADUETO , KAZANO , KOMBIGLYZE , NESINA , ONGLYZA , OSENI , PIOGLIT/GLIM , QTERN , REPAGLINIDE , SOLIQUA , SYNJARDY , TRADJENTA , XIGDUO XR , XULTOPHY 473 KB
PDF File Drug Regimen Optimization - HHSC
Eff. Date: 05/08/2017
 ALTACE, DIOVAN, RAMIPRIL 308 KB
PDF File Dupixent - HHSC
Eff. Date: 08/21/2017
 DUPIXENT 395 KB
PDF File Emflaza - HHSC
Eff. Date: 07/28/2017
 EMFLAZA 411 KB
PDF File Enzymes - HHSC
Eff. Date: 03/30/2018
 ALDURAZYME, ADAGEN, CARBAGLU, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, RAVICTI, VIMIZIM 576 KB
PDF File Erythropoiesis-Stimulating Agents - HHSC
Eff. Date: 10/03/2017
 ARANESP, EPOGEN, PROCRIT 983 KB
PDF File Fentanyl Agents - HHSC
Eff. Date: 05/30/2017
 ABSTRAL, ACTIQ, DURAGESIC, FENTANYL, FENTORA, LAZANDA, SUBSYS 3 MB
PDF File Flexeril/Amrix (Cyclobenzaprine)
Eff. Date: 05/08/2017
 AMRIX, CYCLOBENZAPRINE, FEXMID 306 KB
PDF File GI Motility Agents - HHSC
Eff. Date: 02/12/2018
 AMITIZA, LINZESS, ALOSETRON HCL, LOTRONEX, MOVANTIK, RELISTOR, SYMPROIC, TRULANCE, VIBERZI 976 KB
PDF File GLP1 Receptor Agonist - HHSC
Eff. Date: 04/06/2018
 ADLYXIN, BYDUREON, BYETTA, OZEMPIC, SOLIQUA, TANZEUM, TRULICITY, VICTOZA, XULTOPHY 399 KB
PDF File Growth Hormones
Eff. Date: 06/18/2018
 GENOTROPIN, HUMATROPE, NORDITROPIN NORDIFLEX, NORDITROPIN FLEXPRO, NUTROPIN AQ, OMNITROPE, SAIZEN, TEV-TROPIN 1 MB
PDF File Hepatitis C - Refill - HHSC
Eff. Date: 03/2018
 EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER 77 KB
PDF File Hepatitis C Initial Request - HHSC
Eff. Date: 03/2018
 EPCLUSA, DAKLINZA, HARVONI, MAVYRET, OLYSIO, SOVALDI, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER 102 KB
PDF File Hereditary Angioedema (HAE) - HHSC
Eff. Date: 06/25/2018
 CINRYZE, HAEGARDA 299 KB
PDF File HP Acthar - HHSC
Eff. Date: 10/12/2018
 HP ACTHAR GEL 546 KB
PDF File Imiquimod - HHSC
Eff. Date: 05/18/2018
 ALDARA, IMIQUIMOD, ZYCLARA 315 KB
PDF File Increlex - HHSC
Eff. Date: 05/08/2017
 INCRELEX 873 KB
PDF File Ketorolac (Toradol) - HHSC
Eff. Date: 08/11/2017
 KETOROLAC 507 KB
PDF File Keveyis - HHSC
Eff. Date: 11/03/2017
 KEVEYIS 376 KB
PDF File Lidoderm Patches - HHSC
Eff. Date: 02/15/2018
 LIDOCAINE, LIDODERM 361 KB
PDF File Lovaza - HHSC
Eff. Date:: 04/03/2015
 LOVAZA 355 KB
PDF File Makena (All Plans Except CHC, FCHP, PCHP & TCHP)
Eff. Date: 09/11/2018
 MAKENA 41 KB
PDF File Makena (CHC, FCHP, & TCHP Only)
Eff. Date: 09/11/2018
 MAKENA 40 KB
PDF File Makena (Parkland Only)
Eff. Date: 06/01/2018
 MAKENA 43 KB
PDF File Mobic
Eff. Date: 09/23/2016
 MELOXICAM, MOBIC 685 KB
PDF File Neurontin (Gabapentin) - HHSC
Eff. Date: 12/12/2017
 GABAPENTIN, GRALISE, HORIZANT, NEURONTIN 853 KB
PDF File Nuplazid - HHSC
Eff. Date: 07/28/2017
 NUPLAZID 552 KB
PDF File Opioid Overutilization
Eff. Date: 06/01/2017
 APAP/CAFF/DIHYDROCOD CAP, APAP/COD, ASCOMP/COD CAP, BUTALBITAL/CAFF/APAP/COD, BUTALBITAL/CAFF/ASA/COD CAP, BUTRANS DISC, CAPITAL/COD SUSP, COD SULFATE TAB, DEMEROL, DILAUDID, DOLOPHINE TAB, EMBEDA CAP, ENDOCET TAB, EXALGO TAB, FIORICET/COD CAP, FIORINAL/COD CAP, HYDRCODN/APAP, HYDRCODN/IBU TAB, HYDROMORPHONE, HYSINGLA ER TAB, IBUDONE TAB, KADIAN ER CAP, LORCET, LORTAB, MEPERIDINE INJ, MEPERITAB, METHADONE, METHADOSE, MORPHINE, MS CONTIN CR TAB, NORCO TAB, NUCYNTA, OPANA, OXYCODN, OXYCODN/APAP TAB, OXYCODN/ASA TAB, OXYCODN/IBU TAB, OXYMORPHONE, PERCOCET TAB, REPREXAIN TAB, ROXICODONE TAB, TYLENOL/COD TAB, VICODIN, XARTEMIS XR TAB, XODOL TAB, XOLOX TAB, XTAMPZA ER CAP 143 KB
PDF File Oxycodone Extended Release - HHSC
Eff. Date: 11/20/2017
 OXYCONTIN, OXYCODONE HCL ER, XTAMPZA ER 3 MB
PDF File PCSK9 Inhibitors - HHSC
Eff. Date: 11/17/2016
 PRALUENT, REPATHA 454 KB
PDF File Phenergan (Promethazine) - HHSC
Eff. Date: 02/12/2018
 PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE-CODEINE SYRUP, PROMETHEGAN 370 KB
PDF File Phosphate Binders - HHSC
Eff. Date: 04/02/2018
 AURYXIA, CALCIUM ACETATE, FOSRENOL, LANTHANUM CARB, PHOSLYRA SOL, VELPHORO 284 KB
PDF File Propylthiouracil - HHSC
Eff. Date: 08/11/2017
 PROPYLTHIOURACIL 522 KB
PDF File Provigil - HHSC
Eff. Date: 10/05/2017
 ARMODAFINIL, MODAFINIL, NUVIGIL, PROVIGIL 470 KB
PDF File Ranexa - HHSC
Eff. Date: 11/20/2017
 RANEXA 512 KB
PDF File Revatio - HHSC
Eff. Date: 06/25/2018
 ADCIRCA, REVATIO, SILDENAFIL 381 KB
PDF File Savella - HHSC
Eff. Date: 11/30/2015
 SAVELLA 1 MB
PDF File Symlin - HHSC
Eff. Date: 04/12/2018
 SYMLIN, SYMLINPEN 352 KB
PDF File Thiazolidinediones - HHSC
Eff. Date: 02/08/2018
 ACTOPLUS MET, ACTOPLUS MET XR, ACTOS, DUETACT, AVANDAMET, AVANDARYL, AVANDIA 417 KB
PDF File Topical Acne Agents
Eff. Date: 07/01/2017
 BENZACLIN GEL, CLINDAMY/BEN GEL, ERY/BENZOYL GEL 285 KB
PDF File Topical Immunomodulators Elidel Protopic Eucrisa
Eff. Date: 07/01/2018
 ELIDEL, PROTOPIC, TACROLIMUS, EUCRISA 612 KB
PDF File Topical Retinoids
Eff. Date: 05/01/2018
 ADAPALENE, ADAPALENE-BENZYL PEROX, ATRALIN, AVITA, CLINDA-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA GEL 196 KB
PDF File Tyvaso Starter Kit
Eff. Date: 07/06/2012
 TYVASO 21 KB
PDF File VMAT2 - HHSC
Eff. Date: 07/23/2018
 AUSTEDO, INGREZZA, XENAZINE 553 KB
PDF File Xenical
Eff. Date: 09/21/2018
 XENICAL 44 KB
PDF File Xifaxan (Rifaximin) - HHSC
Eff. Date: 04/12/2018
 XIFAXAN 354 KB
PDF File Xyrem - HHSC
Eff. Date: 04/12/2018
 XYREM 456 KB
PDF File Zelboraf - HHSC
Eff. Date: 04/12/2018
 ZELBORAF 366 KB
PDF File Zyflo
Eff. Date: 1/18/2018
 ZYFLO 290 KB
 

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